ORIGINAL ARTICLE

Evaluation of maxillary arch dimensional and

inclination changes with self-ligating and
conventional brackets using broad archwires
Ezgi Atik,a Bengisu Akarsu-Guven,b Ilken Kocadereli,c and Semra Cigerc
Ankara, Turkey

Introduction: Our objective was to comparatively evaluate different bracket types (conventional, active self-
ligating, and passive self-ligating) combined with broad archwires in terms of maxillary dental arch widths and
molar inclinations. Methods: Forty-six patients aged 13 to 17 years with moderate maxillary and mandibular
crowding and a Class I malocclusion were included in this prospective clinical trial. The primary outcome mea-
sures were changes in maxillary arch width dimensions and molar inclinations. The secondary outcome mea-
sures were changes in maxillary and mandibular incisor inclinations. Group I included 15 patients (mean age,
14.4 6 1.5 years) treated with 0.022-in active self-ligating brackets. Group II included 15 patients (mean age,
14.4 6 1.6 years) treated with 0.022-in Roth prescription conventional brackets. Group III was a retrospective
group of 16 patients (mean age, 14.8 6 1.0 years) previously treated with 0.022-in passive self-ligating
brackets. Each participant underwent alignment with the standard Damon archwire sequence. Whereas the
differences among groups were evaluated by 1-way analysis of variance or Kruskal-Wallis tests, the paired-
samples t test was applied for intragroup comparisons. For all possible multiple comparisons, the Bonferroni
correction was applied to control for type I error. Results: The maxillary intercanine, interpremolar, and intermo-
lar widths were significantly greater after treatment in each bracket group. However, when the levels of expan-
sion achieved among the 3 groups were compared, no significant difference was found. Although all
posteroanterior cephalometric variables showed significant changes during treatment in all groups, these
changes were not significant among the groups. A statistically significant labial proclination of the teeth was
seen in each group. Conclusions: No differences in maxillary arch dimensional changes or molar and incisor
inclination changes were found in conventional and active and passive self-ligating brackets used with broad
archwires. (Am J Orthod Dentofacial Orthop 2016;149:830-7)

N
ew bracket systems with different ligating fea-
tures have been manufactured by almost every
orthodontic company in the last decade.
Different passive and active self-ligating brackets have
been introduced with claims of reduced friction, light
forces, efficient sliding mechanics, and easy clinical
application. No studies support a significant difference
between self-ligating and conventional brackets with
From the Department of Orthodontics, Faculty of Dentistry, Hacettepe Univer-
sity, Ankara, Turkey.
a
Research assistant.
b
Assistant professor.
c
Professor.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Bengisu Akarsu-Guven, Hacettepe University, Fac-
ulty of Dentistry, Department of Orthodontics, Sihhiye, Ankara, Turkey 06100;
e-mail, bengisuakarsu@yahoo.com.
Submitted, December 2014; revised and accepted, November 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.11.024
830
regard to efficiency.1-3 These bracket systems differ
with respect to clip properties, wire types, and
sequences.4-7
The Damon passive self-ligating system introduced
broad archwires and a passive clip with the claim of
posterior expansion with bodily movement or minimal
tipping of the teeth.8 The results of previous studies
indicated greater intermolar arch width increases in
the Damon groups than in the conventional bracket
groups.9-11 Furthermore, a recent study showed that
broader forms of copper-nickel-titanium and stainless
steel archwires in the Damon group could expand the
maxillary arch as much as the conventional straight-
wire system combined with the quad-helix appliance.12
In contrast, several studies have shown no differences
between the Damon passive self-ligating system and
conventional brackets with respect to transverse arch
dimensional changes.13,14 Active and passive self-
ligating systems were also compared according to
maxillary arch dimensional changes.15,16 Transversal
Atik et al
Table I. Demographic and clinical characteristics of the sample
Variable
Age (y)
Sex
Male
Female
Mandibular crowding (mm)
Maxillary crowding (mm)
Treatment duration (mo), median (minimum-maximum)
*The difference between groups II and III was statistically significant (P \0.05); ythe difference between groups I and II was statistically significant
(P 5 0.018).
dimensions at the second premolar and the first molar
were greater in the passive self-ligating group
compared with the active self-ligating group.15 On
the contrary, no difference in maxillary arch dimen-
sional changes during alignment was found among
active self-ligating, passive self-ligating, and conven-
tional brackets.16
Manufacturers of both active and passive self-
ligating brackets have stated the advantages of better
torque control, but wide variations in torque expression
have been reported.17-19 Whereas passive brackets are
claimed to produce a “lip bumper” effect that results
in significantly less labial inclination of the incisors,
the manufacturers of active self-ligating brackets claim
better torque control with the active clip.20
However, the results in the literature do not provide a
clear comparison of these bracket systems in terms of
arch width and incisor and molar inclinations because
different archwire types and sequences are used in
each system. The main purpose of this study was to
comparatively evaluate active self-ligating, passive
self-ligating, and conventional brackets used with broad
Damon archwires in terms of maxillary arch dimensional
and molar inclination changes. The secondary outcome
measures were changes in maxillary and mandibular
incisor inclinations.
MATERIAL AND METHODS
A total of 46 patients who were referred to the
Department of Orthodontics at Hacettepe University,
Ankara, Turkey, were included in this prospective study.
Ethical approval was obtained from the university insti-
tutional review board (number 14/587-25). The patients
were selected according to the following inclusion
criteria: between 13 and 17 years of age at the start of
the treatment, past the pubertal growth spurt, with
moderate maxillary and mandibular crowding and a
American Journal of Orthodontics and Dentofacial Orthopedics
831
Group I, Group II, Group III,
mean (SD) mean (SD) mean (SD)
or n (%) or n (%) or n (%) P value
14.4 (1.5) 14.4 (1.6) 14.8 (1.0) 0.540
0.006
3 (20.0%) 6 (40.0%)* 0 (0.0%)*
12 (80.0%) 9 (60.0%)* 16 (100.0%)*
4.1 (0.99) 3.2 (1.12) 3.8 (0.93) 0.066
4.0 (0.77)y 3.1 (0.74)*,y 3.9 (1.12)* 0.011
14.6 (8.2-22.4) 13.4 (11-25) 13.2 (10-22) 0.965
Class I malocclusion, and nonextraction treatment in
both arches. The levels of crowding for the treatment
groups are shown in Table I. The Hayes-Nance analysis
was used to calculate the levels of maxillary and mandib-
ular crowding on the dental casts taken before the treat-
ment.
Group I included 15 patients (mean age,
14.4 6 1.5 years) treated with the 0.022-in Nexus active
self-ligating bracket (Ormco, Orange, Calif). Group II
included 15 patients (mean age, 14.4 6 1.6 years)
treated with the 0.022-in Roth prescription bracket (For-
estadent, Pforzheim, Germany). The brackets in the con-
ventional bracket group were ligated with stainless steel
ligatures. The patients in groups I and II were prospec-
tively selected and treated by 1 examiner (B.A-G.) based
on the same criteria to select and treat the patients of
group III. The subjects of groups I and II were allocated
sequentially to either treatment system before the start
of treatment. Group III was a retrospective group of 16
patients (mean age, 14.8 6 1.0 years) treated with the
0.022-in Damon 3MX passive self-ligating appliance
system (Ormco/A Company, San Diego, Calif). The pa-
tients in group III were previously treated by a different
examiner (E.A.), and their data were used for this
study.12 For all groups, the following Ormco archwires
were sequentially used: 0.014-, 0.018-, 0.014 3
0.025-, and 0.017 3 0.025-in Damon arch form
copper-nickel-titanium (35
C), followed by 0.017 3
0.025-in and 0.019 3 0.025-in Damon arch form stain-
less steel archwires. All patients had maxillary constric-
tion caused by a dental transverse discrepancy.
Therefore, in all 3 groups, we applied broad Damon
archwires. The archwires were left in place for a mini-
mum of 6 weeks. However, this period was extended un-
til leveling was achieved if necessary.
All mechanics were consistent with a nonextraction
treatment plan. No other appliances, such as headgear,
Herbst, lip bumper, or distalizing appliances, were
June 2016  Vol 149  Issue 6
832 Atik et al

Fig 1. Arch dimension measurements on dental study

casts: 1, intercanine width; 2, interfirst premolar width;
3, intersecond premolar width; 4, intermolar width. Fig 2. Posteroanterior cephalometric measurements: 1,
UR6-ML (
); 2, UR6-ML (mm); 3, UL6-ML (
); 4, UL6-ML
used. In all groups, the appliances were removed, and (mm); 5, UR6-UL6 (mm).
posttreatment records were taken when a Class I
canine-molar relationship and ideal overjet and overbite
were achieved.
A digital caliper was used to measure the following
transverse maxillary dimensions on the pretreatment
(T0) and posttreatment (T1) models: (1) intercanine
width, the distance between the maxillary right and
left canine cusp tips; (2) interfirst premolar width, the
distance between the buccal cusp tips of the maxillary
right and left first premolars; (3) intersecond premolar
width, the distance between the buccal cusp tips of the
maxillary right and left second premolars; and (4) inter-
molar width, the distance between the mesiobuccal cusp
tips of the maxillary right and left first molars (Fig 1).
The pretreatment and posttreatment posteroanterior
and lateral cephalometric radiographs of each subject
were digitally traced using Quick Ceph Studio software
(Quick Ceph Systems, San Diego, Calif). The cephalo-
grams of each patient were traced by 1 examiner
(E.A.). The measurements are illustrated in Figures 2
and 3.
Fig 3. Lateral cephalometric dental angular and linear
measurements: 1, U1-SN (
); 2, U1-FH (
); 3, U1-NA (
);
Statistical analysis
4, U1-NA (mm); 5, IMPA (
); 6, FMIA (
); 7, L1-NB (
); 8,
Data analysis was performed by a private biostatistics L1-NB (mm); 9, overjet (mm); 10, overbite (mm).
expert who was blinded to the groups using SPSS for
Windows (version 11.5; SPSS, Chicago, Ill).
Descriptive statistics were expressed as numbers and test. All variables except treatment duration met the
percentages for sex, medians (minimum and maximum) parametric test assumptions.
for treatment duration, and means and standard devia- The paired t test was used to evaluate the statistical
tions for the rest of the variables. significance of the mean differences between the pre-
The Shapiro-Wilk test was used to determine whether treatment and posttreatment measurements. The mean
the continuous data were normally distributed. Homo- differences among the 3 groups were compared using
geneity of variances was evaluated with the Levene 1-way analysis of variance (ANOVA), and the medians

June 2016  Vol 149  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Atik et al 833

were compared with the Kruskal-Wallis test. If the P

Table II. Reliability results of clinical measurements
value from the 1-way ANOVA was statistically signifi-
cant, the post hoc Tukey honestly significant difference Before treatment After treatment
test was used to determine which group differed from 95% CI 95% CI
which others. Categorical data (sex) were analyzed by
the Pearson chi-square or the Fisher exact test, where ICC Lower Upper ICC Lower Upper
applicable. The intraexaminer reproducibility of the 3-3 (mm) 0.957 0.923 0.976 0.713 0.536 0.830
4-4 (mm) 0.975 0.955 0.986 0.898 0.823 0.942
cephalometric and dental model measurements was as- 5-5 (mm) 0.993 0.987 0.996 0.971 0.949 0.984
sessed by replication of the measurements at 4-week in- 6-6 (mm) 0.958 0.925 0.976 0.948 0.907 0.971
tervals by the same examiner (E.A.). Reliability was UR6-ML (mm) 0.910 0.844 0.949 0.919 0.858 0.954
calculated by intraclass correlation coefficients and UR6-ML (
) 0.944 0.901 0.969 0.942 0.899 0.968
95% confidence intervals for each clinical parameter UL6-ML (mm) 0.907 0.838 0.947 0.869 0.776 0.925
UL6-ML (
) 0.996 0.992 0.998 0.945 0.903 0.969
(Table II). UR6-UL6 (mm) 0.995 0.991 0.997 0.989 0.980 0.994
A P value less than 0.05 was considered statistically sig- U1-NA (
) 0.997 0.995 0.999 0.995 0.991 0.997
nificant. For all possible multiple comparisons, the Bonfer- U1-NA (mm) 0.992 0.985 0.996 0.990 0.982 0.994
roni correction was applied to control for type I error. U1-SN (
) 0.986 0.975 0.992 0.988 0.978 0.993
U1-FH (
) 0.985 0.973 0.992 0.979 0.962 0.988
IMPA (
) 0.993 0.988 0.996 0.995 0.990 0.997
RESULTS FMIA (
) 0.998 0.996 0.999 0.984 0.971 0.991
L1-NB (
) 0.996 0.992 0.998 0.994 0.989 0.997
Baseline demographic and clinical characteristics of L1-NB (mm) 0.997 0.994 0.998 0.998 0.996 0.999
the patients are presented in Table I. Overjet (mm) 0.961 0.931 0.978 0.809 0.681 0.889
Table III shows the mean changes in the maxillary Overbite (mm) 0.978 0.960 0.988 0.925 0.870 0.958
arch width for each appliance system measured from 3, Canine; 4, first premolar; 5, second premolar; 6, first molar; U,
the dental casts. The results showed that intercanine, in- maxillary; R, right; ML, midline; L, left; 1, central incisor; NA,
terfirst premolar, intersecond premolar, and intermolar nasion–A-point; SN, sella-nasion; FH, Frankfort horizontal;
widths were significantly greater after treatment with IMPA, incisor-mandibular plane angle; FMIA, Franfort-
mandibular incisor angle; NB, nasion–B-point.
all appliance systems (Table III). However, when the
levels of expansion achieved among the groups were
compared, no significant difference was found. has not been made for active self-ligating brackets, in
Posteroanterior cephalometric measurements for the which the clip puts pressure on the archwire, unlike in
3 groups at T0 and T1 are shown in Table IV. The angle the passive self-ligating brackets. Because only a few
between the maxillary molar axis and the facial midline studies have evaluated active and passive self-ligating
(UR6-ML and UL6-ML) and the perpendicular distance and conventional brackets in terms of maxillary arch
between the maxillary molars and the facial midline width changes, we aimed to compare these 3 bracket
(UR6-ML and UL6-ML) increased significantly in each types.15,16
treatment group from T0 to T1. However, these measure- A total of 46 skeletal and dental Class I patients with
ments were not significantly different from each other. complete permanent dentitions and moderate maxillary
According to the lateral cephalometric measure- and mandibular crowding were chosen for this study.
ments, the changes in the labiolingual inclination from Subjects who had passed the pubertal growth spurt ac-
T0 to T1 for the maxillary and mandibular teeth, as cording to the Fishman23 maturation levels were
well as the overjet value, were statistically significant preferred to eliminate the effects of growth on the dental
in all bracket systems. No statistically significant differ- arches. The ages of the subjects ranged from 13 to
ence was found in the measurements among all groups 17 years. The amounts of initial crowding were similar
(Table V). (moderate crowding) and not over the limit of the non-
extraction treatment protocol.
The same Damon archwire sequence was used in all 3
DISCUSSION bracket systems in our study. Thus, the confounding ef-
Passive self-ligating brackets have been claimed to fects of different archwire materials and forms were
lead to posterior expansion without prominent labial eliminated, since our initial aim was to demonstrate
movement of the incisors. Based on this idea, conven- the effects of broad Damon archwires on different
tional and passive self-ligating brackets were compared bracket systems.
in terms of maxillary arch dimensional changes in several These results confirmed that arch dimensional
studies.9,21,22 However, the “posterior expansion” claim changes with passive and active self-ligating brackets

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834 Atik et al

Table III. Dental arch width measurements of the groups at T0 and T1

Variable T0 mean (SD) T1 mean (SD) P value* Delta mean (SD) 95% CI P valuey Mean differencez
3-3 0.590
Group I 34.37 (2.78) 36.40 (2.08) \0.0001 2.03 (1.33) 1.29-2.76 0.50 (0.88 to 1.88)
Group II 34.32 (1.92) 36.34 (1.67) \0.0001 2.02 (0.95) 1.49-2.54 0.51 (0.87 to 1.89)
Group III 33.31 (3.20) 35.84 (2.10) 0.0003 2.53 (2.16) 1.38-3.68 0.01 (1.39 to 1.41)
4-4 0.242
Group I 40.56 (2.62) 44.59 (1.85) \0.0001 4.03 (1.53) 3.18-4.87 1.04 (0.65 to 2.74)
Group II 40.77 (2.17) 44.81 (1.90) \0.0001 4.05 (1.75) 3.08-5.02 1.02 (0.68 to 2.71)
Group III 38.22 (2.56) 43.28 (1.96) \0.0001 5.07 (2.41) 3.79-6.35 0.02 (1.74 to 1.70)
5-5 0.024
Group I 46.11 (3.43) 49.63 (3.15) \0.0001 3.52 (1.21) 2.85-4.20 1.38 (0.14 to 2.90)
Group II 46.24 (2.52) 49.47 (2.58) \0.0001 3.23 (0.94) 2.71-3.76 1.67 (0.15 to 3.19)
Group III 42.89 (2.99) 47.79 (2.58) \0.0001 4.9 (2.55) 3.54-6.26 0.29 (1.25 to 1.83)
6-6 0.200
Group I 51.14 (4.25) 53.48 (3.50) \0.0001 2.34 (1.14) 1.71-2.97 1.09 (0.43 to 2.61)
Group II 51.75 (2.50) 54.36 (2.37) 0.0003 2.61 (2.13) 1.43-3.79 0.82 (0.70 to 2.34)
Group III 48.59 (3.27) 52.02 (3.15) \0.0001 3.43 (1.80) 2.47-4.39 0.27 (1.81 to 1.27)
Data are shown as mean differences (95% CI).
3, Canine; 4, first premolar; 5, second premolar; 6, first molar.
*Comparisons between pretreatment and posttreatment measurements within groups; ycomparisons among groups regarding changes in clinical
measurements; according to the Bonferroni correction, P \0.00066 was considered statistically significant; zfirst row, group I vs group III; second
row, group II vs group III; third row, group I vs group II.

Table IV. Posteroanterior cephalometric measurements of the groups at T0 and T1

Variable T0 mean (SD) T1 mean (SD) P value* Delta mean (SD) 95% CI P valuey Mean differencez
UR6-ML (mm) 0.430
Group I 26.00 (1.73) 27.27 (2.01) \0.0001 1.28 (0.71) 0.89-1.67 0.40 (0.50 to 1.30)
Group II 26.90 (1.46) 28.14 (1.60) 0.0003 1.24 (0.99) 0.69-1.79 0.44 (0.46 to 1.34)
Group III 27.87 (1.66) 29.54 (1.99) \0.0001 1.68 (1.30) 0.99-2.37 0.04 (0.88 to 0.95)
UR6-ML (
) 0.833
Group I 24.27 (1.96) 28.26 (2.84) \0.0001 4.00 (2.49) 2.62-5.37 0.05 (2.16 to 2.06)
Group II 24.76 (2.54) 28.27 (1.87) \0.0001 3.51 (2.07) 2.37-4.66 0.43 (1.67 to 2.54)
Group III 26.08 (3.84) 30.03 (3.47) \0.0001 3.95 (2.63) 2.54-5.35 0.48 (1.66 to 2.62)
UL6-ML (mm) 0.997
Group I 26.16 (1.61) 27.13 (2.04) 0.0028 0.97 (1.04) 0.40-1.56 0.01 (0.80 to 0.78)
Group II 27.34 (2.09) 28.33 (1.96) \0.0001 0.99 (0.74) 0.58-1.40 0.02 (0.81 to 0.77)
Group III 28.31 (1.37) 29.27 (1.37) 0.0007 0.97 (0.91) 0.48-1.45 0.02 (0.82 to 0.79)
UL6-ML (
) 0.569
Group I 26.50 (3.91) 29.88 (3.16) \0.0001 3.37 (1.89) 2.33-4.42 0.82 (1.14 to 2.79)
Group II 25.52 (2.70) 29.08 (3.07) 0.0002 3.56 (2.77) 2.03-5.10 0.63 (1.33 to 2.60)
Group III 27.31 (3.49) 31.50 (3.33) \0.0001 4.20 (2.03) 3.12-5.28 0.19 (2.19 to 1.81)
UR6-UL6 (mm) 0.983
Group I 52.28 (2.83) 54.17 (3.00) \0.0001 1.89 (0.86) 1.42-2.37 0.09 (1.29 to 1.11)
Group II 54.30 (3.12) 56.16 (3.29) 0.0002 1.86 (1.47) 1.05-2.68 0.06 (1.26 to 1.14)
Group III 56.98 (2.47) 58.78 (2.73) 0.0006 1.80 (1.65) 0.92-2.68 0.03 (1.19 to 1.25)
Data are shown as mean differences (95% CI).
U, Maxillary; R, right; 6, first molar; ML, midline; L, left.
*Comparisons between pretreatment and posttreatment measurements within groups; ycomparisons among groups regarding changes in clinical
measurements; according to the Bonferroni correction, P \0.00066 was considered statistically significant; zfirst row, group I vs group III; second
row, group II vs group III; third row, group I vs group II.

did not differ from those of conventional brackets after conventional treatment groups. However, in these
treatment (Table III). Pandis et al10,11 and Vajaria et al9 studies, the wire sequences and arch forms differed be-
reported greater intermolar arch width increases in pa- tween the 2 bracket systems. In another study, no dif-
tients treated with the Damon system than in the ference was found in the arch width with the same

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Atik et al 835

Table V. Lateral cephalometric measurements of the groups at T0 and T1

Variable T0 mean (SD) T1 mean (SD) P value* Delta mean (SD) 95% CI P valuey Mean differencez
U1-NA (
) 0.910
Group I 24.13 (6.01) 28.02 (5.68) 0.0009 3.89 (3.61) 1.90-5.89 0.14 (3.73 to 3.45)
Group II 24.95 (5.39) 28.23 (4.79) \0.0001 3.27 (2.41) 1.94-4.61 0.48 (3.11 to 4.07)
Group III 23.17 (7.47) 26.93 (5.37) 0.0163 3.76 (5.56) 0.80-6.72 0.62 (3.03 to 4.26)
U1-NA (mm) 0.732
Group I 4.49 (2.19) 5.92 (2.28) 0.0005 1.44 (1.23) 0.76-2.12 0.34 (1.66 to 0.98)
Group II 5.53 (2.51) 6.56 (2.83) 0.0019 1.03 (1.05) 0.45-1.61 0.07 (1.25 to 1.39)
Group III 5.12 (2.60) 6.22 (1.94) 0.0463 1.10 (2.03) 0.02-2.18 0.41 (0.93 to 1.75)
U1-SN (
) 0.770
Group I 105.25 (6.96) 109.25 (7.90) 0.0035 4.00 (4.42) 1.55-6.45 0.32 (3.46 to 2.82)
Group II 105.84 (5.21) 108.90 (4.81) 0.0003 3.06 (2.44) 1.71-4.41 0.61 (2.52 to 3.75)
Group III 103.63 (7.93) 107.30 (6.74) 0.0011 3.68 (3.64) 1.73-5.62 0.94 (2.25 to 4.13)
U1-FH (
) 0.970
Group I 113.33 (7.40) 116.34 (5.84) 0.0006 3.02 (2.66) 1.55-4.49 0.30 (3.42 to 2.82)
Group II 114.24 (5.49) 117.02 (4.77) 0.0019 2.78 (2.82) 1.22-4.34 0.06 (3.18 to 3.06)
Group III 113.83 (7.06) 116.54 (6.37) 0.0373 2.72 (4.76) 0.18-5.26 0.24 (2.93 to 3.41)
IMPA (
) 0.871
Group I 94.25 (6.04) 100.74 (5.12) \0.0001 5.99 (4.00) 3.78-8.21 0.11 (4.08 to 4.31)
Group II 100.24 (5.29) 106.00 (6.33) 0.0007 5.26 (4.70) 2.66-7.86 0.85 (3.35 to 5.04)
Group III 96.33 (3.40) 102.44 (6.05) 0.0005 6.11 (5.54) 3.15-9.06 0.73 (3.53 to 4.99)
FMIA (
) 0.386
Group I 60.97 (9.26) 55.56 (9.02) 0.0046 5.41 (6.22) 8.85 to 1.96 2.14 (6.84 to 2.55)
Group II 56.74 (5.66) 51.66 (5.74) 0.0010 5.08 (4.75) 7.71 to 2.45 2.47 (7.17 to 2.22)
Group III 60.71 (6.42) 53.16 (6.70) \0.0001 7.55 (5.08) 10.26 to 4.84 0.33 (5.10 to 4.44)
L1-NB (
) 0.921
Group I 25.27 (7.06) 31.48 (5.94) 0.0003 6.21 (5.09) 3.40-9.03 0.39 (3.47 to 4.24)
Group II 29.75 (4.61) 35.71 (5.00) \0.0001 5.96 (3.25) 4.16-7.76 0.64 (3.22 to 4.49)
Group III 26.50 (4.16) 33.10 (4.56) \0.0001 6.60 (4.68) 4.11-9.10 0.25 (3.67 to 4.17)
L1-NB (mm) 0.877
Group I 6.34 (6.23) 8.47 (5.79) \0.0001 2.13 (1.12) 1.51-2.75 0.16 (1.02 to 1.34)
Group II 5.42 (1.94) 7.46 (2.18) \0.0001 2.04 (1.27) 1.34-2.75 0.24 (0.93 to 1.42)
Group III 5.55 (2.45) 7.84 (2.27) \0.0001 2.29 (1.60) 1.44-3.14 0.08 (1.11 to 1.28)
Overjet (mm) 0.863
Group I 3.37 (1.31) 2.45 (1.04) \0.0001 0.93 (0.49) 1.20 to 0.65 0.24 (1.31 to 0.83)
Group II 4.07 (0.95) 3.05 (0.48) 0.0017 1.02 (1.02) 1.58 to 0.45 0.15 (1.22 to 0.93)
Group III 4.04 (1.70) 2.88 (0.63) 0.0191 1.16 (1.77) 2.11 to 0.22 0.09 (1.00 to 1.18)
Overbite (mm) 0.765
Group I 1.39 (1.18) 0.95 (0.72) 0.1377 0.44 (1.08) 1.04 to 0.16 0.22 (0.62 to 1.06)
Group II 1.76 (0.80) 1.55 (0.61) 0.3852 0.21 (0.93) 0.73 to 0.30 0.01 (0.84 to 0.83)
Group III 1.65 (1.23) 1.43 (0.91) 0.3194 0.22 (0.86) 0.68 to 0.24 0.23 (1.08 to 0.63)
Data are shown as mean differences (95% CI).
U, Maxillary; 1, central incisor; NA, nasion–A-point; SN, sella-nasion; FH, Frankfort horizontal; IMPA, incisor-mandibular plane angle; FMIA,
Franfort-mandibular incisor angle; L, mandibular; NB, nasion–B-point.
*Comparisons between pretreatment and posttreatment measurements within groups; ycomparisons among groups regarding changes in clinical
measurements; according to the Bonferroni correction, P \0.00066 was considered statistically significant; zfirst row, group I vs group III; second
row, group II vs group III; third row, group I vs group II.

broad Damon archwire sequence in conventional and
passive self-ligating appliance systems.24 Similar to
our results, the dental arch expansion with self-
ligation could be due to the use of broad archwires
and not to the bracket type.
Unlike in our study, Cattaneo et al15 noted that the
transversal dimensions at the second premolar and the
first molar were greater in the passive self-ligating
group than in the active self-ligating group. The
greater expansion could be due to the broad wires
with the passive self-ligating brackets and the narrow
wires with the active self-ligating brackets. However,
we used broad Damon archwires in each appliance sys-
tem in our study.
Similar to our study, the authors of another study
used the same broad Damon archwires and found no dif-
ference in the arch dimensional changes between the
conventional and either the active or passive

American Journal of Orthodontics and Dentofacial Orthopedics June 2016  Vol 149  Issue 6
836
self-ligating brackets.16 The authors concluded that
bracket type had no significant effect on any transverse
dimensional changes. However, unlike in our study, wide
variations of ethnicity and malocclusions with an espe-
cially high proportion of Class III patients were included
in that study. In our study, we eliminated the malocclu-
sion differences between the groups to negate the con-
founding effects.
The posteroanterior cephalometric evaluation was
performed to determine the degree of tipping of the mo-
lars. In all groups, the increases in UR6-ML and UL6-ML
angles and distances indicated buccal tipping of the
maxillary molars. These increases were not different
from each other in the 3 groups. Therefore, our results
do not agree with the hypothesis of a Fr€ankel-like effect
in the Damon system.8
Atik and Ciger12 and Yu et al25 compared Damon
brackets with conventional systems and found buccal
tipping of the molars in both systems, similar to our re-
sults. However, different from our study, they used
expansion appliances in the conventional groups. Catta-
neo et al15 compared active and passive self-ligating
brackets using cone-beam computed tomography scans
and showed increased buccal tipping of the premolars
and molars in both systems. They concluded that the
claims regarding expansion without tipping using active
or passive self-ligating brackets could not be confirmed.
Fleming et al16 measured molar inclination changes with
different bracket systems using the Orthoanalyzer soft-
ware. They also found the same increases in maxillary
molar inclination in active and passive self-ligating
and conventional brackets.
Nonextraction treatment of crowded maxillary and
mandibular dental arches without distal movement of
the arches requires an increase not only in transverse
dimension but also in incisor proclination.26 In this
study, the patients had nonextraction treatment; there-
fore, we did not need to control anterior torque. Maxil-
lary and mandibular incisor inclination changes were the
same in all groups (Table V). Each bracket system signif-
icantly labially inclined the maxillary and mandibular in-
cisors from T0 to T1. Therefore, the “lip bumper” effect
of the Damon system8 and the claim of better torque
control with the active self-ligating brackets17 were
not supported by our study.
Our finding agrees with that of Pandis et al,10,11,27
who found no significant difference between the self-
ligating and conventional groups in terms of inclination
of the incisors. Cattaneo et al17 compared active and
passive self-ligating brackets on mandibular incisors us-
ing the wire sequences recommended by the manufac-
turers of each system. Similar to our study, they found
no significant difference in inclination between the 2
June 2016  Vol 149  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Atik et al
groups. Fleming et al16 also found that the 3 treatment
systems (active self-ligating, passive self-ligating, and
conventional brackets) inclined the maxillary incisors,
similar to our study. The cephalometric evaluations in
our study showed that the relief of maxillary and
mandibular anterior crowding mainly occurred as a
result of labial inclination independent of the bracket
type.
The limitation of this study might be related to the
fact that different practitioners carried out the treatment
procedures. To reduce the effect of this potential bias,
the same treatment protocol (nonextraction treatment
included the same archwire sequence with no other ap-
pliances) was used by only 2 practitioners (E.A., B.A-G.)
who had been working in the same clinic for several
years, following similar treatment protocols. In addition,
1 group was a retrospective group; this might have
caused bias. Another limitation of the study might be
the small numbers of patients in the groups. However,
the results of this study can be used to design larger
confirmatory studies in the future.
CONCLUSIONS
No differences were found in terms of maxillary arch
dimensional changes and molar and incisor inclination
changes in active self-ligating, passive self-ligating,
and conventional brackets used with broad archwires.
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